USMLE surgery 751to900

A 78-year-old diabetic man has undergone surgical repair of a large abdominal aortic aneurysm. Postoperatively, he develops left lower quadrant abdominal pain followed by bloody diarrhea. He has a history of prostate cancer and received radiation therapy several years ago. He eats a low fiber diet. He quit smoking recently. Vital signs show a low grade fever. Examination shows tenderness in the left lower quadrant and rectal examination reveals blood in the stool. CT scan of the abdomen demonstrates thickening of the colon at the rectosigmoid junction. On colonoscopy, ulcerations are seen in the same area while the colon above and below the lesions is completely normal. Which of the following is the most likely cause of his symptoms?
A 78-year-old diabetic man has undergone surgical repair of a large abdominal aortic aneurysm. Postoperatively, he develops left lower quadrant abdominal pain followed by bloody diarrhea. He has a history of prostate cancer and received radiation therapy several years ago. He eats a low fiber diet. He quit smoking recently. Vital signs show a low grade fever. Examination shows tenderness in the left lower quadrant and rectal examination reveals blood in the stool. CT scan of the abdomen demonstrates thickening of the colon at the rectosigmoid junction. On colonoscopy, ulcerations are seen in the same area while the colon above and below the lesions is completely normal. Which of the following is the most likely cause of his symptoms?
A 78-year-old diabetic man has undergone surgical repair of a large abdominal aortic aneurysm. Postoperatively, he develops left lower quadrant abdominal pain followed by bloody diarrhea. He has a history of prostate cancer and received radiation therapy several years ago. He eats a low fiber diet. He quit smoking recently. Vital signs show a low grade fever. Examination shows tenderness in the left lower quadrant and rectal examination reveals blood in the stool. CT scan of the abdomen demonstrates thickening of the colon at the rectosigmoid junction. On colonoscopy, ulcerations are seen in the same area while the colon above and below the lesions is completely normal. Which of the following is the most likely cause of his symptoms?
A 78-year-old diabetic man has undergone surgical repair of a large abdominal aortic aneurysm. Postoperatively, he develops left lower quadrant abdominal pain followed by bloody diarrhea. He has a history of prostate cancer and received radiation therapy several years ago. He eats a low fiber diet. He quit smoking recently. Vital signs show a low grade fever. Examination shows tenderness in the left lower quadrant and rectal examination reveals blood in the stool. CT scan of the abdomen demonstrates thickening of the colon at the rectosigmoid junction. On colonoscopy, ulcerations are seen in the same area while the colon above and below the lesions is completely normal. Which of the following is the most likely cause of his symptoms?
A 78-year-old diabetic man has undergone surgical repair of a large abdominal aortic aneurysm. Postoperatively, he develops left lower quadrant abdominal pain followed by bloody diarrhea. He has a history of prostate cancer and received radiation therapy several years ago. He eats a low fiber diet. He quit smoking recently. Vital signs show a low grade fever. Examination shows tenderness in the left lower quadrant and rectal examination reveals blood in the stool. CT scan of the abdomen demonstrates thickening of the colon at the rectosigmoid junction. On colonoscopy, ulcerations are seen in the same area while the colon above and below the lesions is completely normal. Which of the following is the most likely cause of his symptoms?
A 78-year-old diabetic man has undergone surgical repair of a large abdominal aortic aneurysm. Postoperatively, he develops left lower quadrant abdominal pain followed by bloody diarrhea. He has a history of prostate cancer and received radiation therapy several years ago. He eats a low fiber diet. He quit smoking recently. Vital signs show a low grade fever. Examination shows tenderness in the left lower quadrant and rectal examination reveals blood in the stool. CT scan of the abdomen demonstrates thickening of the colon at the rectosigmoid junction. On colonoscopy, ulcerations are seen in the same area while the colon above and below the lesions is completely normal. Which of the following is the most likely cause of his symptoms?
A 45-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unable to void. Examination shows blood at the urethral meatus and a scrotal hematoma. His temperature is 370C (98.60F), blood pressure is 100/50, pulse is 100/min and respirations are 16/min. Examination shows a high-riding prostate with no other signs of trauma. Which of the following is the most appropriate next step in management?
A 45-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unable to void. Examination shows blood at the urethral meatus and a scrotal hematoma. His temperature is 370C (98.60F), blood pressure is 100/50, pulse is 100/min and respirations are 16/min. Examination shows a high-riding prostate with no other signs of trauma. Which of the following is the most appropriate next step in management?
A 45-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unable to void. Examination shows blood at the urethral meatus and a scrotal hematoma. His temperature is 370C (98.60F), blood pressure is 100/50, pulse is 100/min and respirations are 16/min. Examination shows a high-riding prostate with no other signs of trauma. Which of the following is the most appropriate next step in management?
Retrograde urethrogram
Diuretic to increase the urine output
Retrograde cystogram with post-void films
A 34-year-old man is brought to the emergency department after being involved in a motorbike accident. Examination shows a hematoma on the forehead and bleeding from his leg. His pupils are bilateral round and reactive; he has papilledema. He responds to pain, has decorticate posture and speaks incoherently. After the initial resuscitation you start the treatment with intravenous fluids, hyperventilation, head elevation and intravenous mannitol. Which of the following is the mechanism of action of hyperventilation in this patient?
Hyperventilation acts as stimuli to brain and helps to arouse the patient
Hyperventilation corrects hypoxia
Hyperventilation helps to wash out the carbon dioxide
Hyperventilation causes vasoconstriction and helps to reduce his bleeding
Hyperventilation causes vasoconstriction and thus decreases the cerebral blood flow
A full-term, female infant is born to a 26-year-old, primigravid mother via C-section secondary to breech position. The mother has lived in New York City for the past 5 years. She denies the use of any drugs, alcohol or cigarettes during her pregnancy. She denies having any sexually transmitted infections. Her lead levels were within the normal range throughout her pregnancy. Prenatal ultrasound done at 30 weeks gestation showed normal anatomy of the fetus. The Apgar scores at 1 and 5 minutes are 7 and 9, respectively. There are some bluish-brown spots located on the infant's lumbosacral area. Flexion and abduction of the lower extremities reveal a palpable clunk. The rest of the physical examination is normal. Which of the following is the best next step in the management of this patient?
Ultrasound of the hips
Reassurance
Ultrasound of the spinal cord
X-ray of the hips
X-ray of the lumbosacral region
A 42-year-old woman is brought to the emergency department after being involved in a motor vehicle collision. On arrival she is unconscious with bilaterally round and reactive pupils. Her temperature is 370 C (98.60 F), blood pressure is 70/20 mm Hg, pulse is 11 0/min and respirations are 22/min. There is a low jugular venous pulse. She does not respond to vocal commands but responds to pain with all 4 limbs. She is not vocalizing. Lung auscultation is unremarkable. Abdominal examination shows a distended abdomen with absent bowel sounds and some bruising. She is intubated and is rapidly infused with 2L of lactated Ringer's solution. Her blood pressure is now 80/30 mm Hg and her pulse is 118/min. Which of the following is the most appropriate next step in management?
X-ray of abdomen
CT scan of hea
Exploratory laparotomy
Lateral x-ray of spine
Chest x-ray
34-year-old man comes to the physician after being involved in a street fight. He has a painful and swollen left arm. Neurovascular examination shows no abnormalities. An x-ray film of the arm shows a fracture of the midshaft of the humerus. Closed reduction of the facture is done and the arm is kept in a hanging cast. One hour later he has numbness of the left wrist and marked limitation of extension at the wrist. Which of the following is the most likely diagnosis?
Radial nerve injury
Brachial artery injury
Compartment syndrome
Ulnar nerve injury
Median nerve injury
A 35-year-old man is brought to the emergency department after he jumped from the fourth floor of a burning building. His temperature is 36.90 C (98.50 F), blood pressure is 90/40, pulse is 90/min, and respirations are 20/min. Examination shows a fracture of the right tibia. He is conscious and his pupils are bilaterally equal and reactive to light and accommodation. His neurological examination shows paraplegia, with loss of pain and temperature in both legs but normal proprioception. Upper extremities do not show any neurological deficits. Passive straight leg raising test is negative. A CT scan of the spine shows a burst fracture at the level of the fourth thoracic vertebra. Which of the following is the most likely diagnosis?
Central cord syndrome
Anterior cord syndrome
Brown Sequard syndrome
Acute disk prolapse
Cauda equine syndrome
A 36-year-old woman is brought to the emergency department after she jumped from the second floor of a burning building. On arrival examination shows an unconscious woman with blood coming from her nose and with an open tibial fracture of left leg. Her eyes are closed and her pupils are equal and responsive bilaterally. She makes muffled sounds and responds to pain by opening the eyes and moving all the limbs. After the initial resuscitation, which of the following is the most appropriate next step in management?
CT scan of head
X-ray of left leg
X-ray of spine
Lumbar puncture
X-ray of head
A 29-year-old woman is brought to the emergency department after burning her right upper extremity in a cooking accident. Examination shows a circumferential burn of the right upper extremity. She is given fluids, an analgesic and a wound dressing. On day three she develops severe deep tissue pain in the right limb with edema of the hand. Examination shows a circumferential eschar over the right arm. Her right radial and ulnar pulses are faint compared to the left and she has paresthesias in her right hand. Which of the following is the most appropriate next step in management?
Increase the dose of her analgesics and discharge her
Do an angiography to assess arterial blood flow
Do an escharotomy
Look for a missed fracture of the right upper limb
Elevation of the limb
A 34-year-old woman is brought to the emergency department after being hit by a motorbike. Examination shows a 3 cm x 2 cm laceration on the left calf. The wound is dirty and the underlying fascia can be seen. She has had four doses of tetanus toxoid in her life; the last dose was 7-years ago. In addition to wound debridement and surgical management, which of the following is the most appropriate course of action to protect her from developing tetanus?
Nothing more is required as the patient is already vaccinated
Give her tetanus immunoglobulin
Give her tetanus toxoid
Give her both tetanus immunoglobulin and tetanus toxoid
Observe the patient and give her tetanus immunoglobulin and tetanus toxoid if she develops any signs of tetanus
Signs of tetanus 761. A 32-year-old man comes to the emergency room (ER) because of acute onset left flank pain, hematuria and vomiting. His pain is relieved with ketorolac in the ER. He has a history of abdominal pain due to Crohn disease, but that pain was always in the rightlower quadrant and was never this severe. His temperature is 36.80 C (98.20 F), blood pressure is 120/65 mm Hg, pulse is 110/min and respirations are 16/min. Chest auscultation is clear. Abdomen is soft and mildly tender over the left flank. He has no rebound or rigidity. Bowel sounds are decreased. A laparotomy scar is present in right lower quadrant. Which of the following is the most likely cause of his symptoms?
Increased recycling of bile salts and fatty acids
Increased absorption of oxalate
Increased absorption of calcium
Increased parathyroid hormone activity
Recurrent bacterial infection in the kidney
54-year-old man comes to the physician because of edema of his right ankle. He reports heaviness and cramping in the same leg that is worse after a long day at work. The swelling is usually reduced significantly when he wakes up in the morning and worsens progressively throughout the day. He denies any other symptoms. He has no significant medical problems except hypertension, for which he takes atenolol. His temperature is 36.7C (98F), blood pressure is 120/76 mm Hg, pulse is 80/min and respirations are 16/min. JVP is normal. Lungs are clearto auscultation. There are no murmurs. There is no hepatosplenomegaly. Examination shows edema of the right ankle. Doppler examination of the leg shows no evidence of thrombosis W hich of the following is the most likely cause of his edema?
Lymphatic obstruction
Impaired cardiac contraction
Reduced diastolic filling of the heart
Increased urinary loss of protein
Venous valve incompetence
Venous valve incompetence@ 763. A 34-year-old man comes to the emergency department because of severe pain in his penis. He was having sex with his wife on top when he had sudden onset severe pain in the penis at the height of orgasm. Swelling of the penis and deviation of the penile shaft to the right followed the pain. Examination shows a man in severe distress. The penis is uncircumcised, grossly swollen and deviated to the right. There is no blood at the urethral meatus. Which of the following is the most appropriate next step in management?
Surgical exploration of penis
Retrograde urethrogram followed by surgical exploration of penis
Foley's catheterization
Antibiotics, analgesics and anti-inflammatory and follow up in 24 hours
Do a circumcision
A 30-year-old man comes to the physician because of a 2-week history of swelling and pain in the right knee. He first experienced pain when he twisted his leg while playing football 15 days ago. He felt something 'popping' in the knee at that time but ignored it. The pain and swelling has been increasing since, and he feels sudden pain with extension of his leg. Examination shows the right knee is swollen and tender along the medial side. Full extension of the right knee is not possible due to sudden pain during terminal extension. Snapping can be felt in the right knee on tibial torsion with the knee flexed at 90 degrees. An x-ray film of the knee joint shows no abnormalities. Which of the following is the most likely diagnosis?
Anterior cruciate ligament injury
Posterior cruciate ligament injury
Medial meniscus tear
Medial collateral ligament tear
Lateral collateral ligament tear
A 34-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He has severe abdominal and left shoulder pain. His temperature is 360 C (96.80 F), blood pressure is 100/60 mm Hg, pulse is 110/min and respirations are 23/min. Examination shows tenderness in the left upper quadrant of the abdomen. An x-ray film of the chest shows fractures of the left 7th, 8th and 9th ribs. A CT scan of the abdomen is suggestive of splenic injury with some free fluid in the abdomen. He has not been vaccinated for H. Influenza or S. pneumoniae. Which of the following is the most important determinant for surgical versus non-surgical management in this patient?
Presence of left shoulder pain
Presence of free fluid in the abdomen
Presence of a rib fracture on chest x-ray
Unvaccinated status of the patient
Hemodynamic stability and hematocrit values
45-year-old woman underwent elective surgery for an inguinal hernia. In the postoperative recovery room, she developed nausea, vomiting, and acute abdominal pain. She has a history of systemic lupus erythematosus, pernicious anemia, type- 1 diabetes, chronic low back pain, and uterine fibroids. Her preoperative medications include monthly vitamin B- 12 injections, insulin, prednisone, hydroxychloroquine, and acetaminophen. Her blood pressure is 70/40 mm Hg and heart rate is 110/min. Initial laboratory studies show a blood glucose of 50 mg/dl. Which of the following is the most likely cause of her condition?
Postoperative bleeding
Diabetic ketoacidosis
Intra-abdominal abscess
Intestinal obstruction
Adrenal insufficiency
46-year-old male is brought to the emergency department after falling on his head and back during a downhill bike race and losing consciousness for 1 minute. He has severe back and abdominal pain. AP and lateral skull films show no abnormalities. Lumbar films show anterior compression wedge fractures of the bodies of L1 and L2. A brace is placed. CT scan of the abdomen shows a mild retroperitoneal bleed and splenic laceration. During the hospitalization he was treated conservatively with analgesics and supportive measures. On hospital day 3, he started to have abdominal distention, pain and nausea. His last bowel movement was 4 days ago and he is not passing gas. His abdomen is distended, tympanic and mildly tender without rebound or guarding. Bowel sounds are absent. An x-ray film of the abdomen is shown below: Which of the following is the most likely diagnosis?
Functional constipation
Paralytic ileus
Large bowel obstruction
Peritonitis
Worsening hematoma
A 55-year-old male Asian immigrant presents to the physician because of recent-onset neck swelling. He also notes having several episodes of epistaxis lately. He has not sustained any trauma to the neck or nose. His past medical history is significant for syphilis and recurrent bacterial sinusitis. He drinks 2 beers daily and has a 30-pack year smoking history. He takes daily multivitamins with antioxidants. On physical examination, you note a mass in the posterior nasal cavity. Biopsy shows undifferentiated carcinoma. Which of the following is a risk factor for this cancer?
Alcohol use
Spirochete infection
Bacterial infection
Viral infection
Vitamin supplements
A 75-year-old woman is brought to the emergency department after falling early in the morning. She is unable to move her right leg and has severe pain in her right hip. Her temperature is 36.90 C (98.60 F), blood pressure is 90/50 mm Hg, pulse is 100/min and respirations are 16/min. Examination shows the right lower extremity is shortened and is externally rotated with marked limitation of hip movement on the right side. An x-ray of the hip shows a markedly displaced fracture of the neck of the right femur. After hemodynamically stabilizing the patient, which of the following is the most appropriate step in management?
Closed treatment in a spica cast
Internal fixation of the fracture
Closed reduction and external fixation
Lower limb skeletal traction
Perform a primary arthroplasty
A 12-year-old boy is brought to the emergency department after falling from a tree. Examination shows tenderness and swelling over the left lower arm. An x-ray film of the arm shows a fracture of the distal end of the humerus with proximal and posterior displacement of the distal fracture segment. Closed reduction of the fracture is performed. However, postoperatively the patient complains of increasing pain in the left arm and forearm. Twelve hours postoperatively his forearm is pale and cold. There is marked pain on passive extension of the fingers. Which of the following is the potential dreaded complication of this condition?
Malunion with alteration of carrying angle
Non-union
Reflex sympathetic dystrophy
Sudeck's atrophy
Volkmann ischemic contracture
A 7-year-old boy has been complaining of left hip pain for the past 8 months. Over recent weeks, he has developed a limp. When you examine his gait, you note that he takes short steps with his left leg. On physical examination, his left hip has significantly limited range of motion, and there is atrophy of the left proximal thigh muscle. X-ray of the patient's pelvis is shown below: W hich of the following is most likely responsible for this patient's condition?
Slipped epiphysis
Bone infection
Osteonecrosis
Muscle dystrophy
Synovitis
A 36-year-old male comes to the emergency department because of worsening right lower quadrant (RLQ) abdominal pain. One week ago he was started on cephalexin for furunculosis. He has had type I diabetes mellitus for 10 years and is on insulin. His temperature is 38.30 C (101.90 F). Examination shows multiple furuncles on the inner side of both thighs; most of them are in regression. Abdominal examination shows tenderness on deep palpation in RLQ without rebound or guarding; no masses are palpated; psoas sign is positive; bowel sounds are present. Rectal examination shows no abnormalities. Laboratory studies show: Hemoglobin 13.0 g/L Leukocyte count 17,500/mm3 Which of the following is the most appropriate next step in management?
Appendectomy
Laparoscopy
CT of abdomen
Colonoscopy
AP and lateral lumbar films
A 68-year-old man comes to the emergency department because of sudden onset back pain. He has never had back pain before and denies any trauma. He does not feel well and feels "like he is going to die". His blood pressure is 70/40 mm Hg, pulse is 110/min and respirations are 20/min. On examination, the abdomen is tender to palpation and there is a large pulsatile mass. Which of the following is the most appropriate next step in management?
Fast track ultrasound
CT scan of abdomen
Abdominal angiogram
Laparotomy
Resuscitate and re-evaluate
A 40-year-old female is brought to the emergency department following a motor vehicle accident in which she was the front seat passenger. She reports hitting her head against the windshield and hurting her right leg. She appears completely alert and oriented. Glasgow Coma Scale = 15/ 15. Her pupils are equal and reactive to light. There is a bruise over the right forehead, but no tenderness is present on palpation of the cranial bones. Examination of the right leg reveals a hematoma over the thigh. Knee extension on the right is markedly reduced when compared to the left. Sensory examination reveals decreased sensory perception to both sharp and dull stimuli over the right lower medial leg. All other dermatomes are intact. What nerve injury is most likely present in this patient?
Femoral nerve
Tibial nerve
Obturator nerve
Common peroneal nerve
Fibular nerve
A 45-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is conscious but in severe pain. His blood pressure is 90/60 mm Hg, pulse is 100/min and respirations are 17/min. Physical examination shows marked swelling and some bruising over the right thigh; the skin is intact. An x-ray film of the leg shows a fracture of the mid shaft of the femur. After hemodynamically stabilizing the patient, which of the following is the most appropriate next step in management?
Open intramedullary nailing of the femur
External fixation of the fracture
Place a plaster cast
Internal fixation of the fracture with plates and screw
Closed intramedullary fixation of the femoral shaft
A 25-year-old man is brought to the emergency department after falling 12m (40ft) from a ladder. He is unconscious. Examination shows obvious head and neck injuries, and a fractured forearm. He is totally apneic. Which of the following would be the best method to establish an immediate definitive airway in this patient?
Nasotracheal intubation
Orotracheal intubation
Needle cricothyroidectomy
Intubation over a fiberoptic bronchoscope
Surgical tracheostomy
A 60-year-old male with a history of ischemic heart disease (IHD) is brought to the emergency department after a motor vehicle accident. On arrival, his blood pressure is 90/60 mm Hg, pulse is 110/min and respirations are 26/min. There are bruises on the left thigh, left side of the chest and tenderness over the same areas. He is started on intravenous normal saline. The presence of which of the following situations would require a blood transfusion in this patient?
Hematocrit less than 35%
Blood loss greater than 1500ml
Evidence of hypoxia
Lactic acidosis
Fracture of femur
A 73-year-old man comes to the physician because of right anterior thigh pain that is worse with walking. He has a history of stable angina, hypertension, hypercholesterolemia, and COPD with periodic exacerbations. He takes ipratropium, aspirin, metoprolol and pravastatin. He smokes 2 packs a day and drinks alcohol occasionally. Physical examination shows a small pulsatile mass in the right groin area. Which of the following is the most likely diagnosis?
Femoral vein aneurysm
Femoral artery aneurysm
Indirect inguinal hernia
Direct inguinal hernia
Femoral hernia
A ​34-year-old woman is admitted for septic shock secondary to a urinary tract infection. In the intensive care unit, she receives dopamine, intravenous fluids and antibiotics and requires central line placement for venous access. Which of the following is the most important safeguard to prevent respiratory and cardiac complications following central line placement?
Insertion via right jugular vein
ECG monitoring
Free aspiration of blood after final catheter placement
Cardiac ultrasound after placement
Chest x-ray confirmation of catheter tip location after placement
A 72-year-old man underwent surgical repair of an aneurysm of the infrarenal aorta. He received perioperative prophylaxis with a second-generation cephalosporin antibiotic. On the first postoperative day he complains of progressive abdominal pain and bloody diarrhea. His temperature is 38.50C (1010F), blood pressure is 110/65 mm Hg, pulse is 110/min and respirations are 22/min. His abdomen is mildly distended and tender to palpation. The tenderness is mostly in the left lower quadrant without rebound. Femoral pulses are full and symmetric. His white blood cell count is 12,000/mm3. Which of the following is the most likely diagnosis?
Pseudomembranous colitis
Invasive infectious diarrhea
Aortoenteric fistula
Ischemia of the bowel
Perforation of the colon
Perforation of the colon 781. A 35-year-old previously healthy male comes to the emergency department because of a 4-hour history of severe abdominal pain. The pain had initially started in the periumbilical area but has now shifted to the right lower quadrant. He also felt nauseated and vomited twice. He has had no previous surgeries. His temperature is 38.90 C (1020 F), blood pressure is 125/80 mm Hg, pulse is 100/min and respirations are 20/min. Examination shows tenderness in the right lower quadrant. Palpation of the left lower quadrant produces pain in the right lower quadrant. Urinalysis is negative. Which of the following is the most appropriate next step in management?
Ultrasound of the abdomen
CT scan of the abdomen
Conservative management
Immediate surgery
Colonoscopy
A 51-year-old male with a history of alcoholic pancreatitis presented to the hospital because of sudden onset severe retrosternal and upper abdominal pain. He has been vomiting for the past few hours after consuming alcohol. His temperature is 38.10 C (100.90 F), blood pressure is 140/90 mm Hg, pulse is 120/min and respirations are 30/min. Examination shows palpable crepitus in the suprasternal notch. Lungs are clear to auscultation. The abdomen is tender to palpation mostly in the epigastrium. Which of the following is the most likely cause of his current condition?
Spontaneous pneumothorax
Acute pancreatitis
Perforated duodenal ulcer
Esophageal perforation
Mallory-Weiss tear
A 12-year-old male is brought to the physician because of a two week history of right groin pain and limping. He is at the 60th percentile for height and the 90th percentile for weight. He is afebrile and his other vital signs are within normal limits. Examination shows the range of motion of the right knee joint is within normal limits, but hip movements are restricted and the right foot points medially. There is marked external rotation of the right thigh on flexion of the hip. After confirming the diagnosis, which of the following is the most appropriate management?
Aspiration and microscopic examination of the hip joint synovial fluid
Conservative management with rest and analgesics
Closed reduction of the hip joint
Immediate osteotomy of the femoral neck
External fixation of the hip joint with pins
A 24-year-old woman comes to the physician's office because of breast pain. She has a 2-month-old baby who she breastfeeds. Her temperature is 38.SC (101.9F). Examination shows a hard, red, tender and swollen area on her right breast. There is no fluctuance noted. Which of the following is the most appropriate next step in management?
Incision and drainage
Recommend mammogram
Antibiotics and lactation suppression with bromocriptine
Antibiotics, analgesics and continue breast feeding
Antibiotics, analgesics and nursing only from unaffected breast
A 23-year-old man comes to the emergency department because of a painful swollen left knee. The pain began after he twisted his leg while playing football. Examination shows a swollen left knee with marked tenderness of the medial side of the knee. When compared to the right knee, on valgus stressing the left knee shows exaggerated laxity at the joint line. Which of the following is the most appropriate next step to confirm the diagnosis?
CT scan of the knee joint
Joint fluid aspiration
Arthroscopy
MRI of the knee joint
Plain radiographs of the knee joint
A one-year-old boy is brought to the emergency department with scalds on both the buttocks and thighs. His mother states that the child was burned because she accidentally drew a bath for the child with water that was too hot. She states the injury occurred 2 days ago. On examination, the child is irritable. Second degree burns are noted on the buttocks, genitalia, waist, proximal thighs and feet. There is an abrupt demarcation between the burned and unaffected skin. A faint yellow patch of discoloration is noted on the left thorax with a slight violaceous hue. The child has not yet had his 1-year vaccinations. Which of the following is the most appropriate next step in management?
Give wound care instructions and send the patient home with analgesics
Admit the patient and do a skeletal survey
Give wound care instructions and advise the mother that she should keep the temperature of the water heater below 140 F to avoid such injuries in future
Ask the mother if the child is being abused
Advise the mother of the suspected abuse, but do not notify authorities because this is a violation of patient confidentiality
A 46-year-old male was admitted with epigastric pain radiating to the back. He has a previous history of endocarditis from intravenous drug use and cellulitis of the arm. Serum lipase is elevated. He was admitted and treated conservatively. Two days later he started to have a fever. He is awake but slightly disoriented. His temperature is 38.70 C (101.60 F), blood pressure is 120/76 mm Hg, pulse is 110/min and respirations are 16/min. He is tremulous and says bugs are crawling on him. His blood cultures are positive for gram negative rods. Empiric antibiotic therapy is started. CT scan of the abdomen shows a new 6 x 6 cm cystic lesion attached to the pancreatic head. Laboratory results show: Hematocrit 44.0 g/L MCV 105fl Leukocyte count 18,500/mm3 Amylase 255 U/L Which of the following is the most appropriate next step in management?
External drainage of the cystic lesion
Continue conservative management
Obtain echocardiogram to evaluate for endocarditis
Obtain Ca 19-9 level for pancreatic cancer
Perform lumbar puncture to rule out meningitis
A 53-year-old male comes to the emergency department complaining of sudden onset intense, stabbing epigastric pain. He also vomited once and a dull, aching pain then spread through his entire abdomen. He has had nonspecific epigastric pain for several months and saw a physician one month ago. He also has a history of constipation, type II diabetes mellitus and hyperlipidemia. He has smoked one and a half packs of cigarettes daily for 26 years. He drinks 4 oz of alcohol daily. His temperature is 38.30 C (100.40 F), blood pressure is 160/95 mm Hg, pulse is 1DO/min and respirations are 26/min. The entire abdomen is tender to palpation with rebound, but there is no guarding. No masses are palpable, and Murphy's sign elicits mild pain. Rectal examination shows no abnormalities. Abdominal ultrasound performed 2 weeks ago showed stones in the gall bladder. Upright chest x-ray is shown below: Which of the following is the most likely diagnosis in this patient?
Acute cholecystitis
Acute alcoholic pancreatitis
Acute gallstone pancreatitis
Perforated peptic ulcer
Perforated diverticulitis
A 40-year-old male developed shortness of breath during the postoperative recovery period. He had a large ventral hernia repair a few hours ago. He has no significant past medical history. He has never smoked. His temperature is 37.60 C (99.80 F), blood pressure is 100/60 mm Hg, pulse is 100/min and respirations are 30/min. Lungs are clear to auscultation except for a few rales at the bases. An x-ray film of the chest shows bibasilar atelectasis. Arterial blood analysis shows: pH 7.35 P02 70 mm Hg PC02 45 mm Hg HC03 28 mEq/L Which of the following is the most appropriate next step in management?
Physiotherapy and respiratory exercises
Begin broad-spectrum antibiotics
Perfusion/ventilation scintigraphy
Administer bronchodilators and steroids
Check serial cardiac enzymes
A 39-year-old paleontologist complains of right-sided hip pain that makes it very difficult for him to lay on his right side while sleeping. He localizes the pain to the outer surface of his thigh. Which of the following is the most likely cause of his pain?
Slipped femoral epiphysis
Paget's disease
Peripheral vascular disease
Trochanteric bursitis
Hip osteoarthritis
A 12-year-old male is brought to the emergency department after direct blunt trauma to the upper abdomen. He has epigastric pain and repeated vomiting immediately after the trauma. He is afebrile and his other vital signs are stable. Barium examination shows duodenal obstruction. CT scan of the abdomen shows a duodenal hematoma and no other injuries are noted. Which of the following is the most appropriate next step in management?
Exploratory laparotomy
Nasogastric suction with parenteral nutrition
Bowel rest and antibiotics
Endoscopic removal of the hematoma
MRI of the abdomen
A 55-year-old man comes to the emergency department because of severe right-sided chest pain. His temperature is 37.80 C (100.40 F), blood pressure is 138/88 mm Hg, pulse is 88/min and respirations are 19/min and shallow. Examination shows decreased respiratory movements on the right side of the chest and tenderness on palpation over the right mid-chest. An x-ray film of the chest shows a fracture of the right 6th rib. Which of the following is the most important goal in management of the rib fracture in this patient?
To achieve a tidal volume of 500 ml with intubation
To use only intravenous colloids
To ensure appropriate analgesia
To provide mechanical stabilization to the chest wall
To give prophylactic antibiotics
A 17-year-old man comes to the physician because a one-week history of fever and abdominal pain. This began with mid-abdominal pain and nausea one week ago, but he was able to continue his usual activities. However, during the past two days, the pain has become worse. It is now localized to the right iliac fossa and impairs walking. He has had two episodes of vomiting during the past several hours. His temperature is 39.40 C (1030 F), blood pressure is 110/70 mm Hg, pulse is 90/min, and respirations are 18/min. Examination shows a tender iliac fossa mass palpated on the right side; remaining abdominal examination shows no rigidity or guarding. Which of the following is the most appropriate next step in management?
Immediate surgery
IV hydration, erythromycin and metronidazole
IV hydration, tetracycline and metronidazole
IV hydration and cefotetan
Ciprofloxacin and vancomycin
A 34-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He was the restrained front passenger. He has had epigastric pain since the accident. He is hemodynamically stable and has no obvious injury or other complaints. An x-ray of the abdomen shows retroperitoneal air. Which of the following is the most appropriate test to confirm the diagnosis?
CT scan of the abdomen without contrast
Diagnostic peritoneal lavage
Colonoscopy
CT scan of the abdomen with oral contrast
Ultrasonogram of the abdomen
A 22-year-old football player comes to the physician because of difficulty in extending his right knee. This started one month ago after he twisted his knee while playing. There was mild swelling immediately; he took pain relievers which relieved both the pain and swelling. However, now the knee motion is limited and this is significantly restricting his physical activities. Physical examination shows no swelling of the knee. While passively flexed and extended, a popping sensation is noted under the examiner's finger (which is placed at the right knee). Which of the following is the most appropriate next step in management?
Bone scan
Lntraarticular steroid injection
Arthroscopy
Active exercise
Rest and NSAIDs
A 34-year-old male is involved in a high-speed highway motor vehicle collision. He is intubated by rescue workers at the accident scene. In the emergency department, the patient has decreased breath sounds on the right side, normal breath sounds on the left, and hypotension. A right-sided chest tube is placed. Physical examination reveals multiple bruises over the entire chest wall as well as subcutaneous emphysema. A few hours later, his chest x-ray shows an accumulation of air in the pleural space as well as pneumomediastinum. Which of the following is the most likely diagnosis?
Myocardial contusion
Bronchial rupture
Myocardial rupture
Esophageal rupture
Diaphragmatic rupture
A 23-year-old man is brought to the emergency department in an obtunded state following a gun-shot wound to the right upper quadrant of the abdomen. His systolic blood pressure is 60 mm Hg and unable to obtain diastolic blood pressure. His pulse is 136/min. Chest auscultation shows clear heart and breath sounds. The abdomen appears distended, and there is an obvious gun-shot wound on the right upper quadrant. The bowel sounds are decreased. Which of the following is the most appropriate next step in management?
Angiography
Diagnostic peritoneal lavage
Focused ultrasonography
Laparoscopy
Laparotomy
While working on-site at a factory doing physical examinations for workers, a physician is suddenly called to help a worker who amputated his finger. Which of the following is the most appropriate next step in management in this situation?
Place the amputated finger in a plastic bag with water and bring it along with the patient to the emergency department
Place the amputated finger in a plastic bag with alcohol; place the bag on a bed of ice and bring it along with the patient to the emergency department
Place the amputated finger in saline moistened gauze in a plastic bag: place the bag on a bed of ice and bring it along with the patient to the emergency department
Place the amputated finger in antiseptic solution and bring it along with the patient to the emergency department
Place the amputated finger on a bed of ice and bring it along with the patient to the emergency department
A 35-year-old woman is brought to the emergency department after being rescued from a burning home by firefighters. She is confused, agitated and tachypneic. Her temperature is 370 C (98.60 F), blood pressure is 100/60 mm Hg, pulse is 130/min and respirations are 24/min. Physical examination shows no burns and her skin color is normal. Auscultation shows normal bilateral air entry with scattered wheezes. Neurological examination shows no abnormalities except some confusion. Abdominal examination shows a soft abdomen; bowel sounds are present. Which of the following is the best immediate treatment for her acute confusional state?
Endotracheal intubation with 100% oxygen
Administration of 100 % oxygen with facemask
Administration of 50% dextrose
Administration of thiamine
Administration of intravenous morphine
A 12-year-old boy is brought to the emergency department after being involved in a motor vehicle collision. He was in the rear seat and was thrown out of the car during the accident. He was immediately resuscitated, and the trauma work-up showed no abnormalities. His discharge was uneventful. Two months later he was seen in the emergency department because of vague chest pain and discomfort. Auscultation showed decreased air entry into the left lower base. An x-ray film of the chest is shown below. Which of the following is the most appropriate next step in management?
Place chest tube
Bronchoscopy
Start antibiotics
Barium swallow
Angiogram
A 22-year-old primigravida woman at 33 weeks gestation is brought to the emergency department after a tonic clonic seizure. On arrival, she also has visual disturbances and a headache. She is given magnesium sulfate and hydralazine. She soon regains consciousness but cannot move her right arm; however, she can move her fingers. Her temperature is 37.20 C (990 F), blood pressure is 160/100 mm Hg, pulse is 110/min and respirations are 20/min. Examination shows her arm extended along the chest and internally rotated. There is no sensory loss on the arm, but there is an inability to externally rotate the shoulder. Deep tendon reflexes (DTR) are intact. Which of the following is the most likely cause of her inability to move her hand?
Todd's paralysis
Magnesium toxicity
Anterior dislocation of shoulder joint
Posterior dislocation of shoulder joint
Dislocation of acromioclavicular joint
A 21-year-old female military recruit presented to the physician's office because of pain in her right foot. The pain started a few weeks ago and initially only occurred with activity, but now the pain is present even at rest. She has no history of obvious trauma. Examination shows swelling and warmth in the foot and point tenderness over the second metatarsal. Plain films of the foot show a hairline fracture of the shaft of the second metatarsal. Which of the following is the most appropriate next step in management?
Bone scan
MRI of the foot
Rest and analgesics
Plaster cast
Surgical intervention
A 15-year-old boy is brought to the physician because of a 15-day history of painful swelling of the right knee. The swelling and redness were immediate after hitting his knee on the door, but have not subsided after 15 days of ibuprofen. He states the pain is increasing. He has no other complaints. His temperature is 37.10C (98.90F), blood pressure is 110/75 mm Hg, pulse is 80/min, and respirations are 22/min. Laboratory studies show a normal ESR and elevated serum alkaline phosphatase. Examination shows the skin is warm and non-tender. An x-ray film of the femur and the knee joint shows an osteolytic lesion of the distal femur along with periosteal inflammation. Which of the following is the most likely diagnosis?
Osteosarcoma
Ewing's sarcoma
Chronic osteomyelitis
Osteoclastoma
Septic arthritis
A 34-year-old male is brought to the emergency department by the paramedics after a gun-shot injury. His temperature is 370 C (98.80 F), blood pressure is 110/60 mm Hg, pulse is 96/min and respirations are 18/min. Examination shows a gunshot entry wound in the left 6th intercostal space anteriorly just lateral to the mid-clavicular line, and an exit wound in left 7th intercostal space posteriorly. After completing the primary survey by attending to airway, breathing and circulation, which of the following is the most appropriate next step in management?
Place a chest tube
Do a diagnostic peritoneal lavage
Pericardiocentesis
Do an exploratory laparotomy
Do a thoracotomy
A 46-year-old male comes to the emergency department because of an abrupt onset of worsening epigastric pain radiating to the back and vomiting. His temperature is 36.50 C (97.60 F), blood pressure is 100/70 mm of Hg, pulse is 100/min and respirations are 20/min. Examination shows a mildly distended abdomen that is very tender to palpation in the epigastric region without rebound; bowel sounds are absent; rectal examination shows no abnormalities. An x-ray film of the abdomen shows gaseous distention of the small bowel in the upper abdomen. CT with contrast shows diffuse hypodense enlargement of the pancreas and peripancreatic and perirenal fluid collections. Nasogastric suction, intravenous normal saline, analgesics and antibiotics are started. Laboratory studies show: Hemoglobin 15.0 g/L Platelets 223,000/mm3 Leukocyte count 14,500/mm3 Serum sodium 134 mEq /L Serum potassium 3.6 mEq/L Chloride 93 mEq/L Bicarbonate 29 mEq/L Blood urea nitrogen (BUN) 30 mg/dL Serum creatinine 0.8 mg/dL Calcium 10.3 mg/dL Blood glucose 168 mg/dL Total bilirubin 1.4 mg/dL Alkaline phosphatase 220 U/L Aspartate aminotransferase (SGOT) 88 U/L Alanine aminotransferase (SGPT) 155 U/L Lipase 523 U/L Which of the following is the most appropriate next step in management?
Add intravenous sodium bicarbonate
Add intravenous pancreatic protease inhibitor
Colonoscopic decompression
Administer intramuscular carbachol to treat ileus
Obtain a right upper quadrant ultrasound
72-year-old man underwent bypass grafting for severe coronary artery disease. On the 1st postoperative day, his temperature is 36.60 C (97.90 F), blood pressure is 120/70 mm Hg, pulse is 80/min and respirations are 12/min. On postoperative day 10 he is complaining of worsening retrosternal pain despite continuing analgesia with morphine. He also has dyspnea at rest. His temperature currently is 37.90 C (100.10 F), blood pressure is 110/70 mm Hg, pulse is 100/min and respirations are 24/min. Examination shows clear heart sounds without murmurs or rubs. EKG shows no acute changes compared to the EKG on the 1st postoperative day. An x-ray film of the chest shows widening of the mediastinum. Echocardiography shows a small amount of pericardial fluid. Laboratory studies show: Hemoglobin 11 .0 g/L Platelets 120,000/mm3 Leukocy1e count 16,500/mm3 Neutrophils 86% Lymphocy1es 13% Prothrombin time 12 sec Partial thromboplastin time 30sec Which of the following will this patient most likely require?
Aspirin therapy
Thoracotomy for debridement and drainage; antibiotic therapy
Thoracotomy for hemostasis
Pericardial puncture and aspirin therapy
Antibiotic therapy alone
Antibiotic therapy alone 807. A 24-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He has severe low back pain. Examination shows weakness and decreased pain and temperature sensation in both legs. Fine touch, vibration, pressure and proprioceptive sensations are intact. He is immobilized and his airway, breathing and circulation are restored. Which of the following is the most appropriate next step in management of his spinal injury?
Immediate surgery
CT scan of the spine
Intravenous steroids
MRI of the spine
Watchful observation
A 34-year-old unrestrained male driver is brought to the ER after a motor vehicle accident. His cervical spine is immobilized. He is stuporous. At the scene of the accident, his blood pressure is 70/30 mm Hg and heart rate is 130/min. Lungs are clear to auscultation. Abdominal wall ecchymosis is present. Abdomen is mildly distended. Bowel sounds are decreased. Neck veins are collapsed. After two liters of intravenous fluids, his blood pressure is 80/40 mmHg. A focused assessment with sonography for trauma shows blood in the peritoneal cavity but no obvious solid organ injury. Which of the following is the most appropriate next step in management?
Laparoscopy
Laparotomy
X-ray films of the abdomen and pelvis
CT scan of the abdomen
Diagnostic peritoneal lavage
A newborn infant is found to have a scrotal mass. The mass is cystic and transilluminated with light. He is born without any other complications. The vital signs are with in normal limits. Other physical examination is unremarkable. Which of the following is the most appropriate next step in management?
Aspiration of fluid
Surgical intervention
Ultrasound examination
Reassurance and observation
Check 24-hour urinary protein excretion
A 37-year-old woman comes to the physician's office because of left breast discomfort. The discomfort has been there for several months, and she recently started having breast pain before menses. Yesterday she noticed a lump in her breast. She has no family history of breast cancer. She smokes one pack of cigarettes every day. She had a baseline mammogram at age 35, which showed no abnormalities. Examination shows a smooth, soft, mobile mass palpable in the upper outer quadrant of the left breast; some diffuse nodularity is present bilaterally. Vital signs are normal. Physical examination otherwise shows no abnormalities. Fine needle aspiration of the mass shows thin greenish, non-bloody fluid; the mass disappears completely after the aspiration. Which of the following is the most appropriate next step in management?
Recommend mammogram to be done as soon as possible
Prescribe oral contraceptives and reassure her
Reassure and reexamine her in six weeks
Send the aspirated fluid for cytologic analysis
Recommend ultrasound evaluation of the aspirated cyst
A 23-year-old woman is brought to the emergency department because of severe respiratory distress. She was stung by a bee one hour ago. Her temperature is 37.10 C (98.80 F), blood pressure is 80/50 mm Hg, pulse is 98/min and respirations are 20/min. Examination shows a conscious woman in severe respiratory distress with audible wheezing. Her skin is warm to palpation. Which of the following is the most appropriate next step in management?
Give her intravenous steroids
Giver her subcutaneous epinephrine
Give her intravenous anti-histamines
Look for the stinger and carefully remove it
Give her oral steroids
A 14-year-old boy is brought to medical attention because of nasal fullness and bleeding. Inspection reveals enlarged cervical lymph nodes as well. Biopsy of a lymphnode confirms nasopharyngeal carcinoma. What is the best management strategy for this patient?
Chemoradiation
External beam radiation therapy
Intracavitary radiation therapy
Surgical resection
Surgical resection followed by adjuvant chemoradiation
A young motorcycle driver is thrown against a concrete bridge abutment and sustains severe trauma about the face, with marked periorbital edema and ecchymosis as well as epistaxis. He is obtunded with rapid, shallow breathing. Which of the following is the next appropriate step in his workup and management?
Evaluation of the cervical spine.
Blind nasopharyngeal intubation with cervical in-line stabilization
Oropharyngeal intubation with cervical in-line stabilization
Emergency tracheostomy
Emergency cricothyroidotomy
A 48-year-old man with a strong history of cigarette use and heavy alcohol intake presents with an intraoral mass. Biopsy shows squamous cell cancer. Chest xray shows hyperinflated lungs but is otherwise normal. Which of the following is indicated as part of his staging workup?
Measurement of serum alkaline phosphatase and calcium levels
Bronchoscopy
Esophagoscopy
Echocardiography
No further workup is necessary
Your patient presents with a complaint of a mass on her right cheek, which has been slowly enlarging. Biopsy shows a pleomorphic adenoma. Which is the next step in her management?
Superficial parotidectomy with preservation of the facial nerve
Superficial parotidectomy with resection of the facial nerve
Total parotidectomy with preservation of the facial nerve
Total parotidectomy with resection of the facial nerve
Enucleation of the adenoma
A 55-year-old man comes to the physician because of chronic leg problems. He has had multiple medical problems and is unable to get good medical care due to lack of insurance. A photograph of his legs is shown below. Which of the following is the most likely cause of his condition?
Arterial thrombosis
Arterial spasm
Venous hypertension
Peripheral neuropathy
Peripheral neuropathy
A 74-year-old woman is admitted with upper gastrointestinal (GI) bleeding. She is started on H 2 blockers, but experiences another bleeding episode. Endoscopy documents diffuse gastric ulcerations. Omeprazole is added to the H2 antagonists as a therapeutic approach to the management of acute gastric and duodenal ulcers. Which of the following is the mechanism of action of omeprazole?
Action of omeprazole? a. Blockage of the breakdown of mucosa-damaging metabolites of nonsteroidal anti-inflammatory drugs (NSAIDs)
Provision of a direct cytoprotective effect
Buffering of gastric acids
Inhibition of parietal cell hydrogen potassium ATPase (adenosine triphosphatase)
Inhibition of gastrin release and parietal cell acid production
A 35-year-old woman presents with frequent and multiple areas of cutaneous ecchymosis. Workup demonstrates a platelet count of 15,000/μL, evaluation of the bone marrow reveals a normal number of megakaryocytes, and ultrasound examination demonstrates a normal-sized spleen. Based on the exclusion of other causes of thrombocytopenia, she is given a diagnosis of immune (idiopathic) thrombocytopenic purpura (ITP). Which of the following is the most appropriate treatment upon diagnosis?
Expectant management with close follow-up of platelet counts
Immediate platelet transfusion to increase platelet counts to greater than 50,000/μL
Glucocorticoid therapy
Intravenous immunoglobulin (IVIG) therapy
Referral to surgery for laparoscopic splenectomy
A 59-year-old woman presents with right lower quadrant pain, nausea, and vomiting. She undergoes an uncomplicated laparoscopic appendectomy. Postoperatively, the pathology reveals a 2.5-cm mucinous adenocarcinoma with lymphatic invasion. Staging workup, including colonoscopy, chest x-ray, and computed tomography (CT) scan of the abdomen and pelvis, is negative. Which of the following is the most appropriate next step in her management?
No further intervention at this time; follow-up every 6 months for 2 years
Chemotherapy alone
Neoadjuvant chemotherapy followed by right hemicolectomy
Ileocecectomy
Right hemicolectomy
A 41-year-old man complains of regurgitation of saliva and of undigested food. An esophagram reveals a dilated oesophagus and a bird’s-beak deformity. Manometry shows a hypertensive lower esophageal sphincter with failure to relax with deglutition. Which of the following is the safest and most effective treatment of this condition?
Medical treatment with sublingual nitroglycerin, nitrates, or calcium-channel blockers
Repeated bougie dilations
Injections of botulinum toxin directly into the lower esophageal sphincter
Dilation with a Gruntzig-type (volume-limited, pressure-control) balloon
Surgical esophagomyotomy
A 32-year-old man with a 3-year history of ulcerative colitis (UC) presents for discussion for surgical intervention. The patient is otherwise healthy and does not have evidence of rectal dysplasia. Which of the following is the most appropriate elective operation for this patient?
Total proctocolectomy with end ileostomy
Total proctocolectomy with ileal pouch-anal anastomosis and diverting ileostomy
Total proctocolectomy with ileal pouch-anal anastomosis, anal mucosectomy, and diverting ileostomy
Total abdominal colectomy with ileal-rectal anastomosis
Total abdominal colectomy with end ileostomy and very low Hartmann
A 39-year-old previously healthy male is hospitalized for 2 weeks with epigastric pain radiating to his back, nausea, and vomiting. Initial laboratory values revealed an elevated amylase level consistent with acute pancreatitis. Five weeks following discharge, he complains of early satiety, epigastric pain, and fevers. On presentation, his temperature is 38.9°C (102°F) and his heart rate is 120 beats per minute; his white blood cell (WBC) count is 24,000/mm3 and his amylase level is normal. He undergoes a CT scan demonstrating a 6 cm by 6 cm rim-enhancing fluid collection in the body of the pancreas. Which of the following would be the most definitive management of the fluid collection?
Antibiotic therapy alone
CT-guided aspiration with repeat imaging in 2 to 3 days
Antibiotics and CT-guided aspiration with repeat imaging in 2 to 3 days
Antibiotics and percutaneous catheter drainage
Surgical internal drainage of the fluid collection with a cyst-gastrostomy or Roux-en-Y cyst-jejunostomy
A previously healthy 79-year-old woman presents with early satiety and abdominal fullness. CT scan of the abdomen, pictured here, reveals a cystic lesion in the body and tail of the pancreas. CT-guided aspiration demonstrates an elevated carcinoembryonic antigen (CEA) level. Which of the following is the most appropriate treatment option for this patient?
Distal pancreatectomy
Serial CT scans with resection if the lesion increases significantly in size
Internal drainage with Roux-en-Y cyst-jejunostomy
Percutaneous drainage of the fluid-filled lesion
Endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic stent placement
A 35-year-old man is brought to the emergency department after he jumped from the fourth floor of a burning building. His temperature is 36.9° C (98.5° F), blood pressure is 90/40, pulse is 90/min, and respirations are 20/min. Examination shows a fracture of the right tibia. He is conscious and his pupils are bilaterally equal and reactive to light and accommodation. His neurological examination shows paraplegia, with loss of pain and temperature in both legs but normal proprioception. Upper extremities do not show any neurological deficits. Passive straight leg raising test is negative. A CT scan of the spine shows a burst fracture at the level of the fourth thoracic vertebra. Which of the following is the most likely diagnosis?
Central cord syndrome
Anterior cord syndrome
Brown Sequard syndrome
Acute disk prolapse
Cauda equine syndrome
A 22-year-old man involved in a motor vehicle collision undergoes a prolonged operation to repair a left femur fracture and femoral artery injury. During the first night after surgery he has pain in the left leg. Despite adequate narcotics, his pain is unremitting; the pain is worse with passive leg movement. Examination shows a pale and swollen leg that is tender to the touch; pulses are palpable. Which of the following is the most appropriate next step in management?
Increase the dose of narcotics
Elevate the leg and place ice packs
Get an x-ray to make sure the femur fracture is not displaced
Go back to the operating room
Go to ICU
A 42-year-old man is brought to the emergency department after a motor vehicle accident. He was a restrained driver and hit a car from behind on a highway. He drank one glass of wine before driving. He occasionally uses cocaine. His medical problems include mild intermittent asthma and peptic ulcer disease. On initial evaluation, his blood pressure is 11 2192 mm Hg and pulse is 96/min. His pulse oximetry shows 95% on room air. Examination shows bruises on the anterior chest wall and abdominal wall. X-rays reveal a fracture of the eighth left rib but no pneumothorax or pleural effusion. Cervical C-spine series are negative. An ultrasound does not show free intraperitoneal fluid. An ECG shows normal sinus rhythm with no ST-segment or T-wave changes. He is treated with intravenous fluids and analgesics. Eight hours later, he complains of epigastric discomfort, left shoulder pain, and mild nausea. His blood pressure is 97/62 mm Hg and pulse is 11 2/min. His pulse oximetry shows 96% on room air. Which of the following is most likely to diagnose this patient's current condition?
Abdominal CT scan with intravenous contrast
Posteroanterior and lateral chest x-ray
Repeat ECG and cardiac biomarkers
Transesophageal echocardiogram
Ventilation-perfusion scan of the lungs
A 30-year-old man comes to the physician because of a 2-week history of swelling and pain in the right knee. He first experienced pain when he twisted his leg while playing football 15 days ago. He felt something 'popping' in the knee at that time but ignored it. The pain and swelling has been increasing since, and he feels sudden pain with extension of his leg. Examination shov1s the right knee is swollen and tender along the medial side. Full extension of the right knee is not possible due to sudden pain during terminal extension. Snapping can be felt in the right knee on tibial torsion with the knee flexed at 90 degrees. An x-ray film of the knee joint shows no abnormalities. Which of the following is the most likely diagnosis?
Anterior cruciate ligament injury
Posterior cruciate ligament injury
Medial meniscus tear
Medial collateral ligament tear
Lateral collateral ligament tear
A 25-year-old male is brought to the emergency department following a motor vehicle accident in which he was the unrestrained driver. The emergency response team's reports indicate that his breath smelled of alcohol at the scene. En route to the hospital, the patient receives 2 liters of intravenous normal saline, and in the ED his blood pressure is 100/60 mmHg, heart rate is 120/min, and respiratory rate is 34/min. His neck veins are flat. You note multiple bruises overlying his anterior chest wall and upper abdomen. On inspiration, there is inward motion of the right side of his chest wall. His abdomen is soft and non-distended. He is put on positive pressure mechanical ventilation and his chest movements become symmetric. Which of the following is the most likely diagnosis?
Tracheobronchial disruption
Esophageal rupture
Flail chest
Pneumothorax
Air embolism
A 55-year-old man comes to the emergency department because of severe right-sided chest pain. His temperature is 37.8° C (1000 F), blood pressure is 138/88 mm Hg, pulse is 88/min and respirations are 19/min and shallow. Examination shows decreased respiratory movements on the right side of the chest and tenderness on palpation over the right mid-chest. An x-ray film of the chest shows a fracture of the right 6th rib. Which of the following is the most important goal in management of the rib fracture in this patient?
To achieve a tidal volume of 500 ml with intubation
To use only intravenous colloids
To ensure appropriate analgesia
To provide mechanical stabilization to the chest wall
To give prophylactic antibiotics
A 5-year-old child presents with a small mass near the anterior border of the sternocleidomastoid muscle. The mass is associated with localized erythema and induration, and the child is febrile. Which of the following is the definitive treatment of this problem?
Antibiotic therapy
Incision and drainage
Incision and drainage followed by complete excision after resolution of the inflammation and infection
Partial excision followed by clinical observation
Immediate excision followed by postoperative antibiotic therapy for 1 week
A 21-year-old woman asks you to evaluate a small painless lump in the midline of her neck that moves with swallowing. You make the clinical diagnosis of thyroglossal duct cyst. Which of the following is the most appropriate management of this patient?
Excision of the cyst
Excision of the cyst and the central portion of the hyoid bone
Excision of the cyst, the central portion of the hyoid bone, and the tract to the base of the tongue
Excision of the cyst, the central portion of the hyoid bone, and the tract to the base of the tongue, with sampling of central cervical lymph nodes
Excision of the cyst, the central portion of the hyoid bone, and the tract to the base of the tongue, with biopsy of the thyroid gland
A 60-year-old smoker is seen because of a 3-cm midline ulcerating mass that is visualized when he sticks out his tongue. Biopsy establishes that this is squamous cell carcinoma. Which of the following is the most appropriate treatment of his cancer?
Radiation therapy alone
Partial glossectomy
Partial glossectomy and cervical lymph node sampling
Partial glossectomy and bilateral neck dissections
Partial glossectomy followed by chemoradiation
A 56-year-old woman is referred to you about 3 months after a colostomy subsequent to a sigmoid resection for cancer. She complains that her stoma is not functioning properly. Which of the following is the most common serious complication of an end colostomy?
Bleeding
Skin breakdown
Parastomal hernia
Colonic perforation during irrigation
Stomal prolapse
A 56-year-old previously healthy physician notices that his eyes are yellow and he has been losing weight. On physical examination the patient has jaundice and scleral icterus with a benign abdomen. Transcutaneous ultrasound of the abdomen demonstrates biliary ductal dilation without gallstones. Which of the following is the most appropriate next step in the workup of this patient?
Esophagogastroduodenoscopy (EGD)
Endoscopic retrograde cholangiopancreatography (ERCP)
C. Acute abdominal series
Computed tomography (CT) scan
Positron emission tomography (PET) scan
A 45-year-old woman with history of heavy nonsteroidal anti-inflammatory drug ingestion presents with acute abdominal pain. She undergoes exploratory laparotomy 30 hours after onset of symptoms and is found to have a perforated duodenal ulcer. Which of the following is the procedure of choice to treat her perforation?
Simple closure with omental patch
Truncal vagotomy and pyloroplasty
Truncal vagotomy and antrectomy
Highly selective vagotomy with omental patch
Hemigastrectomy
A 45-year-old man with a history of chronic peptic ulcer disease undergoes a truncal vagotomy and antrectomy with a Billroth II reconstruction for gastric outlet obstruction. Six weeks after surgery, he returns, complaining of postprandial weakness, sweating, light-headedness, crampy abdominal pain, and diarrhea. Which of the following would be the best initial management strategy?
Treatment with a long-acting somatostatin analog
Dietary advice and counseling that symptoms will probably abate within 3 months of surgery
Dietary advice and counseling that symptoms will probably not abate but are not dangerous
Workup for neuroendocrine tumor (eg, carcinoid)
Preparation for revision to Roux-en-Y gastrojejunostomy
A 60-year-old male patient with hepatitis C with a previous history of variceal bleeding is admitted to the hospital with hematemesis. His blood pressure is 80/60 mmHg, physical examination reveals splenomegaly and ascites, and initial hematocrit is 25%. Prior to endoscopy, which of the following is the best initial management of the patient?
Administration of intravenous octreotide
Administration of a β-blocker (eg, propranolol)
Measurement of prothrombin time and transfusion with cryoglobulin if elevated
Empiric transfusion of platelets given splenomegaly
Gastric and esophageal balloon tamponade (Sengstaken-Blakemore tube)
A 32-year-old alcoholic with end-stage liver disease has been admitted to the hospital 3 times for bleeding esophageal varices. He has undergone banding and sclerotherapy previously. He admits to currently drinking a 6 packs of beer per day. On his abdominal examination, he has a fluid wave. Which of the following is the best option for long-term management of this patient’s esophageal varices?
Orthotopic liver transplantation
Transection and reanastomosis of the distal esophagus
Distal splenorenal shunt
End-to-side portocaval shunt
Transjugular intrahepatic portosystemic shunt (TIPS)
A 55-year-old man complains of chronic intermittent epigastric pain. A gastroscopy demonstrates a 2-cm prepyloric ulcer. Biopsy of the ulcer yields no malignant tissue. After a 6weeks trial of medical therapy, the ulcer is unchanged. Which of the following is the best next step in his management?
Repeat trial of medical therapy
Local excision of the ulcer
Highly selective vagotomy
Partial gastrectomy with vagotomy and Billroth I reconstruction
Vagotomy and pyloroplasty
45-year-old man was discovered to have a hepatic flexure colon cancer during a colonoscopy for anemia requiring transfusions. Upon exploration of his abdomen in the operating room, an unexpected discontinuous 3-cm metastasis is discovered in the edge of the right lobe of the liver. Preoperatively, the patient was counseled of this possibility and the surgical options. Which of the following is the most appropriate management of this patient?
A diverting ileostomy should be performed and further imaging obtained
Right hemicolectomy
Right hemicolectomy with local resection of the liver metastasis
Closure of the abdomen followed by chemotherapy
Right hemicolectomy with postoperative radiation therapy to the liver
A 42-year-old man with no history of use of NSAIDs presents with recurrent gastritis. The patient was diagnosed and treated for Helicobacter pylori 6 months ago. Which of the following tests provides the least invasive method to document eradication of the infection?
Serology testing for H pylori
Carbon-labeled urea breath test
Rapid urease assay
Histologic evaluation of gastric mucosa
Culturing of gastric mucosa
A 22-year-old college student notices a bulge in his right groin. It is accentuated with coughing, but is easily reducible. Which of the following hernias follows the path of the spermatic cord within the cremaster muscle?
Femoral
Direct inguinal
Indirect inguinal
Spigelian
Interparietal
An 80-year-old man with history of symptomatic cholelithiasis presents with signs and symptoms of a small-bowel obstruction. Which of the following findings would provide the most help in ascertaining the diagnosis?
Coffee-grounds aspirate from the stomach
Pneumobilia
A leukocyte count of 40,000/mL
A pH of 7.5, PCO2 of 50 kPa, and paradoxically acid urine
A palpable mass in the pelvis
A 42-year-old man has bouts of intermittent crampy abdominal pain and rectal bleeding. Colonoscopy is performed and demonstrates multiple hamartomatous polyps. The patient is successfully treated by removing as many polyps as possible with the aid of intraoperative endoscopy and polypectomy. Which of the following is the most likely diagnosis?
Ulcerative colitis
Villous adenomas
Familial polyposis
Peutz-Jeghers syndrome
Crohn colitis
A 70-year-old woman has nausea, vomiting, abdominal distention, and episodic crampy midabdominal pain. She has no history of previous surgery but has a long history of cholelithiasis for which she has refused surgery. Her abdominal radiograph reveals a spherical density in the right lower quadrant. Which of the following is the definitive treatment for this patient’s bowel obstruction?
Ileocolectomy
Cholecystectomy
Ileotomy and extraction
Nasogastric (NG) tube decompression
Intravenous antibiotics
A 35-year-old man is brought to the emergency department after a motorcycle accident. He is unconscious when the emergency medical team arrived. He regains consciousness on the way to the emergency department. Upon arrival, he is mildly confused and complains of headache and nausea. His temperature is 36.9° C (98.5° F), blood pressure is 102/60 mm Hg, pulse is 116/min, and respirations are 22/min. Pupils are equal and reactive to light. He moves all extremities on command, and deep tendon reflexes are symmetric. Head CT scan shows: Which of the following is the most likely diagnosis?
Acute epidural hematoma
Acute subdural hematoma
Concussion
Diffuse axonal injury
Lntracerebral bleeding
A 65-year-old male presented to the ER with increasing shortness of breath, fever and productive cough of 2 days duration. He has smoked for several years and has been on home oxygen. Chest x-ray showed right lower lobe consolidation. His vital signs on admission were temperature 38.7°C (101.7°F), blood pressure 120/76 mm Hg, and pulse 110/min and respirations 26/min. His condition worsened over the next several hours and required orotracheal intubation and mechanical ventilation. He was transferred to the intensive care unit. Placement of a central venous catheter in the right subclavian vein for IV access was attempted. After the line is successfully placed, the patient begins to deteriorate. Repeat vital signs are blood pressure 80/50 mm Hg and pulse 130/min. Examination shows absent breath sounds on the right side and distended neck veins. Which of the following is the most appropriate next step in management?
Stat chest x-ray
Arterial blood gas analysis
Pericardiocentesis
Needle thoracostomy
Intravenous fluids and dopamine
A 54-year-old woman comes to the clinic because of a forceful hyperextension injury to her hand after falling down. She complains of pain and swelling of the right wrist and pain associated with movement. She has no other complaints. She has no other medical conditions and takes no medication. Her blood pressure is 110/60 mm Hg, pulse is 84/min, and respirations are 12/min. Examination shows maximal tenderness in the anatomic snuffbox and pain with radial deviation of the wrist. The rest of the examination shows no other injuries. X-ray imaging of the wrist in multiple views does not reveal a fracture. Which of the following is the most appropriate next step in management?
Administer analgesics and recommend rest
Obtain an ultrasonogram of the wrist
Place a thumb spica cast and repeat the radiography in 7- 10 days
Obtain a DEXA scan to screen for osteoporosis
Administer a steroid injection
An 18-year-old woman at 9 weeks' gestation is brought to the emergency department because of an open fracture of the tibia and fibula. She is hemodynamically stabilized and referred to the orthopedic department. She is scheduled for internal fixation of the tibia for the following day. However, before the surgery she develops severe dyspnea and confusion. Her temperature is 37.7° C (99.9° F), blood pressure is 110/70 mmHg, pulse is 110/min, and respirations are 22/min. Examination shows numerous non-palpable petechiae in the upper part of the body. Which of the following is the most likely diagnosis?
Air embolism
Amniotic fluid embolism
Thromboembolism
Fat embolism
Acute respiratory distress syndrome
A 46-year-old man is brought to the emergency department after a fall during a downhill bike race. He lost consciousness for approximately 1 minute after the fall. He complains of severe back and abdominal pain. He has no other medical problems. Head computed tomography (CT) scan shows no intracranial bleeding. Lumbar films suggest a compression wedge fracture of the body of L2 vertebra, and a brace is placed. Abdominal CT scan shows a small retroperitoneal bleed and splenic laceration. He is conservatively treated with analgesics and supportive measures. On hospital day three, he complains of abdominal pain and nausea. His abdomen is distended, tympanic, and mildly tender, without rebound or guarding. Bowel sounds are absent. X-ray of the abdomen reveals:
Erosive gastritis
Expanding retroperitoneal hematoma
Colonic pseudoobstruction
Mesenteric ischemia
Paralytic ileus
A 22-year-old man who was involved in a motor vehicle accident undergoes intravenous fluid resuscitation with 2 L normal saline over 20 minutes. He is in respiratory distress, with a respiratory rate of 40/min. He receives bilateral chest tubes. Endotracheal intubation is performed and mechanical ventilation is initiated due to progressive respiratory failure. His blood pressure is 92/50 mm Hg and pulse is 121/min. The patient is responsive to painful stimuli only. Pulmonary examination shows coarse breath sounds bilaterally. The chest x-ray is shown below. Which of the following most likely contributed to this patient's progressive respiratory failure?
Diaphragmatic tear
Esophageal rupture
Flail chest
Pulmonary edema
Tension pneumothorax
A 38-year-old woman who underwent total thyroidectomy for multinodular goiter 6 months ago presents with persistent hoarseness. Which of the following nerves was most likely injured during her operation?
Superior laryngeal nerve
Bilateral recurrent laryngeal nerves
Unilateral recurrent laryngeal nerve
Hypoglossal nerve
Marginal mandibular branch of the facial nerve
A 4-year-old boy is brought into the emergency room by his parents for difficulty in breathing and swallowing. On physical examination the child is febrile, tachycardic, and tachypneic. He is anxious, drooling, and becomes increasingly exhausted while struggling to breathe. A lateral cervical spine radiograph is shown here. Which of the following is the most appropriate management of this patient?
Examine the larynx at bedside
IV antibiotics and admission to the floor
Immediate endotracheal intubation in the emergency room
Immediate endotracheal intubation in the operating room
Immediate tracheostomy in the operating room
A 58-year-old man is found to have a small mass in the right neck on a yearly physical examination. The patient reports that the mass has been slowly growing for the last few months and is not associated with pain or drainage. He has an otherwise negative review of systems. On examination there is a hard, mobile 2 cm mass along the mid-portion of the right sternocleidomastoid muscle. Which of the following is the most appropriate initial step in the workup of the neck mass?
No further workup is needed. Reevaluate the mass after a course of antibiotics for 2 weeks.
Fine-needle aspiration (FNA).
Core needle biopsy.
Incisional biopsy
Excisional biopsy
A 53-year-old man presents to the emergency room with left lower quadrant pain, fever, and vomiting. CT scan of the abdomen and pelvis reveals a thickened sigmoid colon with inflamed diverticula and a 7-cm by 8-cm rim-enhancing fluid collection in the pelvis. After percutaneous drainage and treatment with antibiotics, the pain and fluid collection resolve. He returns as an outpatient to clinic 1 month later. He undergoes a colonoscopy, which demonstrates only diverticula in the sigmoid colon. Which of the following is the most appropriate next step in this patient’s management?
Expectant management with sigmoid resection if symptoms recur
Cystoscopy to evaluate for a fistula
Sigmoid resection with end colostomy and rectal pouch (Hartmann procedure)
Sigmoid resection with primary anastomosis
Long-term suppressive antibiotic therapy
A 29-year-old woman complains of postprandial right upper quadrant pain and fatty food intolerance. Ultrasound examination reveals no evidence of gallstones or sludge. Upper endoscopy is normal, and all of her liver function tests are within normal limits. Which of the following represents the best management option?
Avoidance of fatty foods and reexamination in 6 months.
Ultrasound examination should be repeated immediately, since the falsenegative rate for ultrasound in detecting gallstones is 10% to 15%.
Treatment with ursodeoxycholic acid.
CCK-HIDA scan should be performed to evaluate for biliary dyskinesia. @
Laparoscopic cholecystectomy for acalculous cholecystitis
A 47-year-old asymptomatic woman is incidentally found to have a 5-mm polyp and no stones in her gallbladder on ultrasound examination. Which of the following is the best management option?
A. Aspiration of the gallbladder with cytologic examination of the bile
Observation with repeat ultrasound examinations to evaluate for increase in polyp size
Laparoscopic cholecystectomy
Open cholecystectomy with frozen section
In bloc resection of the gallbladder, wedge resection of the liver, and portal lymphadenectomy
A 48-year-old woman develops pain in the right lower quadrant while playing tennis. The pain progresses and the patient presents to the emergency room later that day with a low-grade fever, a WBC count of 13,000/mm3 and complaints of anorexia and nausea as well as persistent, sharp pain of the right lower quadrant. On examination, she is tender in the right lower quadrant with muscular spasm, and there is a suggestion of a mass effect. An ultrasound is ordered and shows an apparent mass in the abdominal wall. Which of the following is the most likely diagnosis?
Acute appendicitis
Cecal carcinoma
Hematoma of the rectus sheath
Torsion of an ovarian cyst
Cholecystitis
A 32-year-old alcoholic man, recently emigrated from Mexico, presents with right upper quadrant pain and fevers for 2 weeks. CT scan of the abdomen demonstrates a non–rim-enhancing fluid collection in the periphery of the right lobe of the liver. The patient’s serology is positive for antibodies to Entamoeba histolytica. Which of the following is the best initial management option for this patient?
Treatment with antiamebic drugs
Percutaneous drainage of the fluid collection
Marsupialization of the fluid collection
Surgical drainage of the fluid collection
Liver resection
A 45-year-old executive experiences increasingly painful retrosternal heartburn, especially at night. He has been chewing antacid tablets. An esophagogram shows a hiatal hernia. In determining the proper treatment for a sliding hiatal hernia, which of the following is the most useful modality?
Barium swallow with cinefluoroscopy during Valsalva maneuver
Flexible endoscopy
Twenty-four-hour monitoring of esophageal pH
Measurement of the size of the hernia on upper GI
Assessment of the patient’s smoking and drinking history
A 22-year-old woman is seen in a surgery clinic for a bulge in the right groin. She denies pain and is able to make the bulge disappear by lying down and putting steady pressure on the bulge. She has never experienced nausea or vomiting. On examination she has a reducible hernia below the inguinal ligament. Which of the following is the most appropriate management of this patient?
Observation for now and follow-up in surgery clinic in 6 months
Observation for now and follow-up in surgery clinic if she develops further symptoms
Elective surgical repair of hernia
Emergent surgical repair of hernia
Emergent surgical repair of hernia with exploratory laparotomy to evaluate the small bowel
A 22-year-old woman presents with a painful fluctuant mass in the midline between the gluteal folds. She denies pain on rectal examination. Which of the following is the most likely diagnosis?
Pilonidal abscess
Perianal abscess
Perirectal abscess
Fistula-in-ano
Anal fissure
A 72-year-old man status post–coronary artery bypass graft (CABG) 5 years ago presents with hematochezia, abdominal pain, and fevers. Colonoscopy reveals patches of dusky-appearing mucosa at the splenic flexure without active bleeding. Which of the following is the most appropriate management of this patient?
Angiography with administration of intra-arterial papaverine
Emergent laparotomy with left hemicolectomy and transverse colostomy
Aortomesenteric by pass
Exploratory laparotomy with thrombectomy of the inferior mesenteric artery
Expectant management
A 62-year-old man has been diagnosed by endoscopic biopsy as having a sigmoid colon cancer. He is otherwise healthy and presents to your office for preoperative consultation. He asks a number of questions regarding removal of a portion of his colon. Which of the following is most likely to occur after a colon resection?
The majority (> 50%) of normally formed feces will comprise solid material
Patients who undergo major colon resections suffer little long-term change in their bowel habits following operation
Sodium, potassium, chloride, and bicarbonate will be absorbed by the colonic epithelium by an active transport process.
The remaining colon will absorb less water.
The remaining colon will absorb long-chain fatty acids that result from bacterial breakdown of lipids.
A 39-year-old woman with no significant past medical history and whose only medication is oral contraceptive pills (OCP) presents to the emergency room with right upper quadrant pain. CT scan demonstrates a 6-cm hepatic adenoma in the right lobe of the liver. Which of the following describes the definitive treatment of this lesion?
Cessation of oral contraceptives and serial CT scans
Intra-arterial embolization of the hepatic adenoma
Embolization of the right portal vein
Resection of the hepatic adenoma
Systemic chemotherapy
A 43-year-old man without symptoms is incidentally noted on CT scan to have a 4 cm lesion in the periphery of the left lobe of the liver. The lesion enhances on the arterial phase of the CT scan and has a central scar suggestive of focal nodular hyperplasia (FNH). Which of the following is the recommended treatment of this lesion?
No further treatment is necessary
Wedge resection of the lesion
Formal left hepatectomy
Intra-arterial embolization of the lesion
Radiofrequency ablation of the liver lesion
A 57-year-old previously alcoholic man with a history of chronic pancreatitis presents with hematemesis. Endoscopy reveals isolated gastric varices in the absence of esophageal varices. His liver function tests are normal and he has no stigmata of end-stage liver disease. Ultrasound examination demonstrates normal portal flow but a thrombosed splenic vein. He undergoes banding, which is initially successful, but he subsequently rebleeds during the same hospitalization. Attempts tocontrol the bleeding endoscopically are unsuccessful. Which of the following is the most appropriate next step in management?
Transjugular intrahepatic portosystemic shunt
Surgical portocaval shunt
Surgical mesocaval shunt
Splenectomy
Placement of a Sengstaken-Blakemore tube
A previously healthy 15-year-old boy is brought to the emergency room with complaints of about 12 hours of progressive anorexia, nausea, and pain of the right lower quadrant. On physical examination, he is found to have a rectal temperature of 38.18°C (100.72°F) and direct and rebound abdominal tenderness localizing to McBurney point as well as involuntary guarding in the right lower quadrant. At operation through a McBurney-type incision, the appendix and cecum are found to be normal, but the surgeon is impressed by the marked edema of the terminal ileum, which also has an overlying fibrinopurulent exudate. Which of the following is the most appropriate next step?
Close the abdomen after culturing the exudate
Perform a standard appendectomy.
Resect the involved terminal ileum
Perform an ileocolic resection
Perform an ileocolostomy to bypass the involved terminal ileum
A 32-year-old woman undergoes a cholecystectomy for acute cholecystitis and is discharged home on the sixth postoperative day. She returns to the clinic 8 months after the operation for a routine visit and is noted by the surgeon to be jaundiced. Laboratory values on readmission show total bilirubin 5.6 mg/dL, direct bilirubin 4.8 mg/dL, alkaline phosphatase 250 IU (normal 21-91 IU), serum glutamic oxaloacetic transaminase (SGOT) 52 kU (normal 10-40 kU), and serum glutamic pyruvic transaminase (SGPT) 51 kU (normal 10-40 kU). An ultrasonogram shows dilated intrahepatic ducts. The patient undergoes the transhepatic cholangiogram seen here. Which of the following is the most appropriate next management step?
Choledochoplasty with insertion of a T tube
End-to-end choledochocholedochal anastomosis
Roux-en-Y hepaticojejunostomy
Percutaneous transhepatic dilatation
Choledochoduodenostomy
After complete removal of a sessile polyp of 2.0 cm by 1.5 cm found 1 finger length above the anal mucocutaneous margin, the pathologist reports it to have been a villous adenoma that contained carcinoma in situ. Which of the following is the most appropriate next step in management?
Reexcision of the biopsy site with wider margins
Abdominoperineal rectosigmoid resection
Anterior resection of the rectum
External radiation therapy to the rectum
No further therapy
No further therapy @ 871. A 62-year-old man has been noticing progressive difficulty swallowing, first solid food and now liquids as well. A barium study shows a ragged narrowing just below the carinal level. Endoscopic biopsy confirms squamous cell carcinoma. Which of the following provides the most accurate information regarding the T stage of an esophageal carcinoma?
Computed tomography
Positron emission tomography
Magnetic resonance imaging
Endoscopic ultrasound
Bronchoscopy
A 53-year-old woman with a history of a vagotomy and antrectomy with Billroth II reconstruction for peptic ulcer disease presents with recurrent abdominal pain. An esophagogastroduodenoscopy (EGD) demonstrates that ulcer and serum gastrin levels are greater than 1000 pg/mL on three separate determinations (normal is 40-150). Which of the following is the best test for confirming a diagnosis of gastrinoma?
A 24-hour urine gastrin level
A secretin stimulation test
A serum glucagon level
A 24-hour urine secretin level
A serum glucose to insulin ratio
A 52-year-old man with a family history of multiple endocrine neoplasia type 1 (MEN1) has an elevated gastrin level and is suspected to have a gastrinoma. Which of the following is the most likely location for his tumor?
Fundus of the stomach
Antrum of the stomach
Within the triangle formed by the junction of the second and third portions of the duodenum, the junction of the neck and body of the pancreas, and the junction of the cystic and common bile duct Q
Tail of the pancreas
Within the triangle formed by the inferior edge of the liver, the cystic duct, and the common hepatic duct
A 73-year-old woman presents to the emergency room complaining of severe epigastric pain radiating to her back, nausea, and vomiting. CT scan of the abdomen demonstrates inflammation and edema of the pancreas. A right upper quadrant ultrasound demonstrates the presence of gallstones in the gallbladder. Which of the following is an important prognostic sign in acute pancreatitis according to Ranson’s criteria?
Amylase level
Age
Total bilirubin level
Albumin level
Lipase level
A 55-year-old man who is extremely obese reports weakness, sweating, tachycardia, confusion, and headache whenever he fasts for more than a few hours. He has prompt relief of symptoms when he eats. Labarotory examination reveals an inappropriately high level of serum insulin during the episodes of fasting. Which of the following is the most appropriate treatment for this condition?
Diet modification to include frequent meals
Long-acting somatostatin analogue octreotide
Simple excision of the tumor
Total pancreatectomy
Chemotherapy and radiation
A 57-year-old woman sees blood on the toilet paper. Her doctor notes the presence of an excoriated bleeding 2.8-cm mass at the anus. Biopsy confirms the clinical suspicion of anal cancer. In planning the management of a 2.8-cm epidermoid carcinoma of the anus, which of the following is the best initial management strategy?
Abdominoperineal resection
Wide local resection with bilateral inguinal node dissection
Local radiation therapy
Systemic chemotherapy
Combined radiation therapy and chemotherapy
An 80-year-old man is admitted to the hospital complaining of nausea, abdominal pain, distention, and diarrhea. A cautiously performed transanal contrast study reveals an apple-core configuration in the rectosigmoid area. Which of the following is the most appropriate next step in his management?
Colonoscopic decompression and rectal tube placement
Saline enemas and digital disimpaction of fecal matter from the rectum
Colon resection and proximal colostomy
Oral administration of metronidazole and checking a Clostridium difficile titer
Evaluation of an electrocardiogram and obtaining an angiogram to evaluate for colonic mesenteric ischemia
40-year-old female is brought to the emergency department following a motor vehicle accident in which she was the front seat passenger. She reports hitting her head against the windshield and hurting her right leg. She appears completely alert and oriented. Glasgow Coma Scale =15/15. Her pupils are equal and reactive to light. There is a bruise over the right forehead, but no tenderness is present on palpation of the cranial bones. Examination of the right leg reveals a hematoma over the thigh. Knee extension on the right is markedly reduced when compared to the left. Sensory examination reveals decreased sensory perception to both sharp and dull stimuli over the medial side of the right lower thigh and leg. All other dermatomes are intact. What nerve injury is most likely present in this patient?
Femoral nerve
Tibial nerve
Obturator nerve
Common peroneal nerve
Fibular nerve
28-year-old man is brought to the emergency department after being an unrestrained passenger in a motor vehicle collision. In the ambulance on the way to the hospital, he receives 2 L normal saline intravenously and 5 Umin of oxygen by nasal cannula. His blood pressure is 80/42 mm Hg, pulse is 135/min, and respirations are 40/min. He is agitated and moves all 4 extremities spontaneously. His pupils are symmetric and reactive to light. Neck veins are distended, and his trachea is deviated to the right. Which of the following is the best initial management for this patient?
Chest tube placement in the fifth intercostal space in the left midaxillary line
Chest x-ray to confirm pneumothorax
Endotracheal intubation to establish an adequate airway
Imaging to exclude cervical spine injury
Needle insertion into the second intercostal space in the left midclavicular line
A 46-year-old woman who was recently diagnosed with Crohn disease asks about the need for surgery. Which of the following findings would be an indication for an immediate exploratory laparotomy?
Intestinal obstruction
Enterovesical fistula
Ileum-ascending colon fistula
Enterovaginal fistula
Free perforation
A 50-year-old man presents to the emergency room with a 6-hour history of excruciating abdominal pain and distention. The abdominal film shown here is obtained. Which of the following is the most appropriate next diagnostic maneuver?
Emergency celiotomy
Upper GI series with small-bowel follow-through
CT scan of the abdomen
Barium enema
Sigmoidoscopy
A septuagenarian woman undergoes an uncomplicated resection of an abdominal aneurysm. Four days after surgery the patient presents with sudden onset of abdominal pain and distention. An abdominal radiograph demonstrates an air-filled, kidney-bean–shaped structure in the left upper quadrant. Which of the following is the most appropriate management at this time?
Decompression of the large bowel via colonoscopy
Placement of the NG tube and administration of low-dose cholinergic drugs
Administration of a gentle saline enema and encouragement of ambulation
Operative decompression with transverse colostomy
Right hemicolectomy
A 45-year-old man presents with right upper quadrant abdominal pain and fever. CT scan shows a large, calcified cystic mass in the right lobe of the liver. Echinococcus is suggested by the CT findings. Which of the following is the most appropriate management of echinococcal liver cysts?
Percutaneous catheter drainage
Medical treatment with albendazole
Medical treatment with steroids
Medical treatment with metronidazole.
Total pericystectomy
A 28-year-old woman who is 15 weeks pregnant has new onset of nausea, vomiting, and right sided abdominal pain. She has been free of nausea since early in her first trimester. The pain has become worse over the past 6 hours. Which of the following is the most common non-obstetric surgical disease of the abdomen during pregnancy?
Appendicitis
Cholecystitis
Pancreatitis
Intestinal obstruction
Acute fatty liver of pregnancy
A 56-year-old woman has nonspecific complaints that include an abnormal sensation when swallowing. An esophagram is obtained. Which of the following is most likely to require surgical correction?
Large sliding esophageal hiatal hernia
Paraesophageal hiatal hernia
Traction diverticulum of esophagus
Schatzki ring of distal esophagus
Esophageal web
A 65-year-old man who is hospitalized with pancreatic carcinoma develops abdominal distention and obstipation. The following abdominal radiograph is obtained. Which of the following is the most appropriate initial management of this patient?
Urgent colostomy or cecostomy
Discontinuation of anticholinergic medications and narcotics and correction of metabolic disorders
Digital disimpaction of fecal mass in the rectum
Diagnostic and therapeutic colonoscopy
Detorsion of volvulus and colopexy or resection
A 48-year-old man presents with jaundice, melena, and right upper quadrant abdominal pain after undergoing a percutaneous liver biopsy. Endoscopy shows blood coming from the ampulla of Vater. Which of the following is the most appropriate first line of therapy for major hemobilia?
Correction of coagulopathy, adequate biliary drainage, and close monitoring
Transarterial embolization (TAE)
Percutaneous transhepatic biliary drainage (PTBD)
Ligation of bleeding vessels
Hepatic resection
A 30-year-old female patient who presents with diarrhea and abdominal discomfort is found at colonoscopy to have colitis confined to the transverse and descending colon. A biopsy is performed. Which of the following is a finding consistent with this patient’s diagnosis?v
The inflammatory process is confined to the mucosa and submucosa.
The inflammatory reaction is likely to be continuous
Superficial as opposed to linear ulcerations can be expected.
Noncaseating granulomas can be expected in up to 50% of patients
Microabscesses within crypts are common
A 24-year-old man presents to the emergency room with abdominal pain and fever. CT scan of the abdomen reveals inflammation of the colon. He is referred to a gastroenterologist to be evaluated for inflammatory bowel disease (Crohn disease versus ulcerative colitis). Which of the following indications for surgery is more prevalent in patients with Crohn disease?
A 24-year-old man presents to the emergency room with abdominal pain and fever. CT scan of the abdomen reveals inflammation of the colon. He is referred to a gastroenterologist to be evaluated for inflammatory bowel disease (Crohn disease versus ulcerative colitis). Which of the following indications for surgery is more prevalent in patients with Crohn disease?
Massive bleeding
Fistulas between the colon and segments of intestine, bladder, vagina, urethra, and skin
Intractable disease
Dysplasia or carcinoma
A 62-year-old man presents with a 3-month history of an enlarged lymph node in the left neck. He is a long-time smoker of cigarettes and denies fevers, night sweats, fatigue, or cough. On physical examination there is a 1.5 cm hard, fixed mass below the angle of the mandible in the left neck. Which of the following is the most likely cause of an enlarged lymph node in the neck?
Thyroglossal duct cyst
Dermoid tumor
Carotid body tumor
Branchial cleft cyst
Metastatic squamous cell carcinoma
An upper GI series is performed on a 71-year-old woman who presented with several months of chest pain that occurs when she is eating. The film shown here is obtained. Investigation reveals a microcytic anemia and erosive gastritis on upper endoscopy. Which of the following is the most appropriate initial management of this patient?
Cessation of smoking, decreased caffeine intake, and avoidance of large meals before lying down
Antacids
Histamine-2 blocker
Proton-pump inhibitor
Surgical treatment
A 54-year-old man complains that his eyes are yellow. His bilirubin is elevated. His physical examination is unremarkable. A CT of the abdomen shows a small mass in the head of the pancreas encasing the superior mesenteric artery. Cytology from the ERCP is positive for cancer. Which of the following is the most appropriate treatment for this patient?v
Pancreaticoduodenectomy
Pancreaticoduodenectomy with reconstruction of the superior mesenteric artery
Total pancreatectomy
Total pancreatectomy with reconstruction of the superior mesenteric artery
Chemoradiation therapy
A 28-year-old woman presents with hematochezia. She is admitted to the hospital and undergoes upper endoscopy that is negative for any lesions. Colonoscopy is performed and no bleeding sources are identified, although the gastroenterologist notes blood in the right colon and old blood coming from above the ileocecal valve. Which of the following is the test of choice in this patient?
Angiography
Small-bowel enteroclysis
CT scan of the abdomen
Technetium 99m (99mTc) pertechnetate scan
Small-bowel endoscopy
A 32-year-old woman undergoes an uncomplicated appendectomy for acute appendicitis. The pathology report notes the presence of a 1-cm carcinoid tumor in the tip of the appendix. Which of the following is the most appropriate management of this patient?
Right hemicolectomy
Right hemicolectomy and chemotherapy
Chemotherapy only
Radiation only
No further treatment
A 44-year-old man is brought to the emergency department after a motor vehicle accident. His cervical spine is immobilized and 2 large-bore intravenous lines are placed. His breath smells of alcohol. The patient is lethargic but responds to commands appropriately. A 3-cm laceration is present on his forehead. Ecchymoses are seen on his back and over the abdominal wall in the distribution of the seat belt. The lungs are clear to auscultation. The trachea is midline and the neck veins are collapsed. Passive movement of the right hip is limited due to pain. At the scene of the accident, blood pressure was 90/60 mm Hg and pulse was 130/min. After receiving a 1 L bolus of intravenous fluids, the patient's blood pressure remains 90/60 mm Hg and his pulse is now 122/min. Portable chest x-ray shows no pneumothorax or pleural effusions. A bedside abdominal ultrasound is inconclusive for hemoperitoneum or intra-abdominal injury due to poor image quality. What is the most appropriate next step in management of this patient?
Computed tomography scan of the abdomen
Computed tomography scan of the head
Diagnostic peritoneal lavage
Immediate laparotomy
Plain x-ray films of the abdomen
A 43-year-old mildly overweight female complains of periodic right knee swelling and pain with physical activity for the past three months. She says that this problem started while on a hiking trip three months ago, at which point she experienced a 'popping' sensation in her right knee. She recalls that her knee was swollen the next day, and responded to over-the-counter pain killers. Recently, she has been having to limit her physical activities due to knee pain. On physical examination, there is tenderness of the anterior and medial right knee joint. Which of the following is the most likely diagnosis?
Anterior cruciate ligament tear
Meniscal tear
Osteoarthritis
Patellar tendonitis
Anserine bursitis
A 53-year-old male is brought to the emergency room after a high-speed motor vehicle accident. He was an unrestrained driver and admits to consuming a moderate amount of alcohol before driving. In the ER, he complains of bilateral chest pain and left leg pain. His past medical history is significant for emphysema, diabetes mellitus and remote drug abuse. A traumatic fracture of the left femur is evident on physical examination. His initial arterial blood gas analysis shows a pH of 7.45, p02 of 81 mmHg and pC02 of 32 mmHg. His pulmonary capillary wedge pressure is 1OmmHg. After a 2000 ml IV fluid challenge, his p02 is 76 mmHg and his pulmonary capillary wedge pressure is 12 mmHg. Chest x-ray shows alveolar opacities over the right and left lower lobes. Hours after the accident, he complains of continued chest pain and shortness of breath. Which of the following diagnoses is most likely responsible for his shortness of breath?
Aspiration pneumonia
Hemothorax
Pulmonary contusion
Myocardial contusion
Aortic rupture
35-year-old woman presents with abdominal pain and jaundice. Subsequent ERCP reveals the congenital cystic anomaly of her biliary system illustrated in the film shown here. Which of the following is the most appropriate treatment?
Cholecystectomy with resection of the extrahepatic biliary tract and Roux-en-Y hepaticojejunostomy
Internal drainage via choledochoduodenostomy
Internal drainage via choledochocystojejunostomy
Percutaneous transhepatic biliary drainage
Liver transplantation
A 36-year-old man is in your intensive care unit on mechanical ventilation following thoracotomy for a 24-hour-old esophageal perforation. His WBC is markedly elevated, and he is febrile, hypotensive, and coagulopathic. His NG tube fills with blood and continues to bleed. Which of the following findings on upper endoscopy would be most suspicious for stress gastritis?
Multiple, shallow lesions with discrete areas of erythema along with focal hemorrhage in the antrum
Multiple, shallow lesions with discrete areas of erythema along with focal hemorrhage in the fundus
Multiple deep ulcerations extending into and through the muscularis mucosa in the antrum
Multiple deep ulcerations extending into and through the muscularis mucosa in the antrum
Single deep ulceration extending into and through the muscularis mucosa in the fundus
A 35-year-old man presents with right upper quadrant pain, fever, jaundice, and shaking chills. Ultrasound of the abdomen demonstrates gallstones, normal gallbladder wall thickness, and common bile duct of 1.0 cm. The patient is admitted to the hospital and given IV fluids and antibiotics. He continues to be febrile with increasing WBCs. Which of the following is the most appropriate next step in this patient’s management?
Endoscopic retrograde cholangiopancreatography (ERCP)
Placement of a cholecystostomy tube
Laparoscopic cholecystectomy
Open cholecystectomy
Emergent operation and decompression of the common bile duct with a T tube
{"name":"USMLE surgery 751to900", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"A 78-year-old diabetic man has undergone surgical repair of a large abdominal aortic aneurysm. Postoperatively, he develops left lower quadrant abdominal pain followed by bloody diarrhea. He has a history of prostate cancer and received radiation therapy several years ago. He eats a low fiber diet. He quit smoking recently. Vital signs show a low grade fever. Examination shows tenderness in the left lower quadrant and rectal examination reveals blood in the stool. CT scan of the abdomen demonstrates thickening of the colon at the rectosigmoid junction. On colonoscopy, ulcerations are seen in the same area while the colon above and below the lesions is completely normal. Which of the following is the most likely cause of his symptoms?, A 45-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unable to void. Examination shows blood at the urethral meatus and a scrotal hematoma. His temperature is 370C (98.60F), blood pressure is 100\/50, pulse is 100\/min and respirations are 16\/min. Examination shows a high-riding prostate with no other signs of trauma. Which of the following is the most appropriate next step in management?, A 34-year-old man is brought to the emergency department after being involved in a motorbike accident. Examination shows a hematoma on the forehead and bleeding from his leg. His pupils are bilateral round and reactive; he has papilledema. He responds to pain, has decorticate posture and speaks incoherently. After the initial resuscitation you start the treatment with intravenous fluids, hyperventilation, head elevation and intravenous mannitol. Which of the following is the mechanism of action of hyperventilation in this patient?","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
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